State Form Number (SFN) 14543

Equal Employment Opportunity Discrimination Questionnaire/Affidavit

Instructions for SFN 14543

If you believe that you have been unlawfully discriminated against regarding your employment rights and would like
the North Dakota Department of Labor and Human Rights' assistance, you may complete and return the Employment Discrimination Intake
Questionnaire. The intake questionnaire provides the department with information to determine if your concerns fall
within the scope of our authority. The department is able to accept complaints of unlawful discrimination based on
race, color, religion, sex, disability, age, national origin, marital status, receipt of public assistance, or lawful
activity off the employer's premises outside of regular work hours which is not in direct conflict with the
business-related interests of the employer. This means actions that are "because of" one or more these
factors can be addressed.

Please answer the items on the questionnaire completely and specifically so that we can fully assess your situation.
Please type or write your answers legibly, using additional paper if necessary. Incomplete questionnaires will be
returned for completion. Copies of any records or documents you have that support your claim should also be submitted
with the completed questionnaire.

If the department determines that it does have a legal basis to proceed, it will generate a formal charge, which
will be mailed to you. You will be asked to review the charge, sign it, and return it to the Department of Labor and Human Rights. Upon
receipt of the signed charge, the department will dual-file the complaint with the federal Equal Employment Opportunity
Commission if it also meets federal jurisdiction. This is done under Department of Labor and Human Rights' work-sharing agreement
with the federal agency, which establishes that the department will investigate complaints of employment discrimination
for the federal agency.

If the department determines that it does not have a legal basis to proceed, you will be notified in writing and
given the opportunity to provide further information if applicable. Please be advised that there are many acts
that may seem unfair that do not constitute unlawful discrimination.

Timeliness is important when filing your concerns. There is a 300-day limitation, from the date of the alleged
discriminatory act, within which the signed formal complaint must be returned to the department. Keep in mind that the
intake questionnaire must be submitted in time to allow the department to assess the initial information, acquire any
additional information necessary, and process a formal complaint before the time limit expires.